I regrettably must point out that this document contains confusing, irrelevant, inconsistent, or redundant text, and (as evidenced by the multiple suggestions offered by my Grammerly addon) could generally use a good editor.
I recommend identifying the services described as specifically “Targeted Case Management” and “TCM” (and not just “Case Management” or “CM”) throughout this document.
TABLE OF CONTENTS – the page numbers are not in sequential order and are inaccurate
The terms “Brain Injury” and “Traumatic Brain Injury” are defined inconsistently in the document, both in the DEFINITIONS section and in the “Medical Necessity Criteria” subsection of the BIS CASE MANAGEMENT ELIGIBILITY DETERMINATION section. I recommend using the definition for brain injury already provided in Section 37.2-403 of the Code of Virginia: "Brain injury" means any injury to the brain that occurs after birth that is acquired through traumatic or non-traumatic insults. Non-traumatic insults may include but are not limited to anoxia, hypoxia, aneurysm, toxic exposure, encephalopathy, surgical interventions, tumor, and stroke. "Brain injury" does not include hereditary, congenital, or degenerative brain disorders, or injuries induced by birth trauma. (see https://law.lis.virginia.gov/vacode/title37.2/chapter4/section37.2-403/)
I suggest that the definition for traumatic brain injury (TBI) be simplified to that used by BIAA: an alteration in brain function, or other evidence of brain pathology, caused by an external force.”
I suggest changing the definition of Brain Injury Services Case Management (BIS CM) to:
“Brain Injury Services Targeted Case Management” (BIS TCM) means those case management services provided under the state plan to target services for those with severe Traumatic Brain Injury (TBI).
I recommend changing the last bulleted item in the Case Management definition to read:
Educating and counseling the individual and/or family/caregivers to guide them to develop supportive relationships that promote the… While this definition ends with “individual support plan”, this term is not defined (although the term “Plan of Care (POC)” is – see more below).
The definition of Certified Brain Injury Specialist (CBIS) should be in parentheses. I suggest correcting that CBIS requires an annual renewal, and that the link for more information go to BIAA’s ACBIS web page at https://www.biausa.org/professionals/acbis.
For continuity with the definition of DBHDS, I recommend removing “Virginia” and “(DMAS) from the “DMAS” definition.
Might the definition of “Face-to-face contact” include telehealth meetings (especially if requested by the individual being served)?
I suggest that the specific phrase “the Mayo Portland Adaptability Inventory version 4 (MPAI 4)” is used to define itself – it is redundant and should be removed. I recommend the definition read:
“Mayo Portland Adaptability Inventory (MPAI-4)” means an evaluation tool that measures functional outcomes for individuals with brain injury during the post-acute (posthospital) period.
I recommend changing the term “Plan of Care (POC)” to “Individual Support Plan (ISP), as already defined in Virginia’s Administrative Code (see https://law.lis.virginia.gov/admincode/title12/agency30/chapter122/section190/ )
CM Agency Requirements - I am concerned that case management provider agencies are required to “guarantee that individuals have access to emergency services on a 24-hour basis” without any definition or description of what this guarantee entails. Must an agency provide services 24 hours per day? What is the nature of the required coordination with MCOs and DBHDS administered crisis services?
CM Staff Qualifications/Credentials – “counseling” degrees are mentioned twice here. I recommend expanding the acceptable bachelor’s degree to include other human services degrees, as well as allowing those with similar previous job experience. I also suggest allowing those with other clinical Virginia licenses (LCSW, LMFT, LPC, LSATP) to qualify.
I am concerned about the conflation of the QBISP certificate with the CBIS certification; they are NOT equivalent accomplishments. QBISP may be desirable in an applicant for the TCM job, but CBIS certification should be required after some time.
Assessment and Service Initiation Process – This section describes requiring an evaluation visit to a person’s residence before the delivery of TCM services to conduct an assessment for service planning and begin the MPAI-4 assessment and the person-centered planning process. This requirement is NOT person-centered, as it allows no option for an individual seeking services to have a say in where their services begin. As someone who once provided home-based mental health services, I also know how dangerous this can be without getting some sense of the individual and their family first.
Item 3 describes needing documentation “verifying freedom of choice of providers” for services. The “CM Agency Requirements” portion of the PROVIDER REQUIREMENTS section describes how HCBS providers CANNOT provide case management so long as “the only willing and qualified entity to provide case management... in a geographic area” does not provide HCBS. This appears to me to limit Targeted Case Management services to ONLY one entity per geographic area, so long as that entity does not provide HCBS. How is this “freedom of choice” when there is only one provider in a given area?
Item 8 requires face-to-face contact every 90 calendar days. This contradicts the 60-day requirement described in the COVERED SERVICES and “Person-Centered Planning” sections earlier in this document.
CLAIMS AND BILLING
The fourth paragraph reads: Reimbursement shall be provided only for "active" case management clients, as defined.” Unfortunately, “active” case management is NOT defined anywhere.